O0400B3A: Occupational Therapy Co-Treatment, Step-by-Step
Step-by-Step Coding Guide for O0400B3A: Occupational Therapy Co-Treatment
1. Review of Medical Records
Objective: Confirm whether the resident received co-treatment occupational therapy within the 7-day look-back period.
Actions:
- Access the resident’s medical records, including therapy treatment notes, interdisciplinary care plans, and progress reports.
- Verify the occurrence of co-treatment sessions where two therapists from different disciplines provided therapy simultaneously.
- Ensure the sessions were clinically justified for the resident and included distinct interventions from each therapist.
2. Understanding Definitions
O0400B3A: Co-Treatment in Occupational Therapy: This refers to therapy sessions where two clinicians from different disciplines (e.g., OT and PT) treat a single resident at the same time. Each therapist provides a different treatment, and both may report the full session time as co-treatment.
- Co-treatment: Occurs when two therapists from different disciplines (e.g., OT and PT) treat the resident simultaneously with different goals or treatments. Both disciplines may record the time spent as co-treatment.
- Concurrent Therapy: Two residents are treated simultaneously, but are performing different tasks under the same therapist's supervision.
- Group Therapy: Two to six residents perform the same or similar activities under the supervision of one therapist.
3. Coding Instructions
Step-by-Step:
- Step 1: Confirm that two therapists from different disciplines provided therapy simultaneously to the same resident.
- Step 2: Identify the specific therapy sessions that included occupational therapy as one of the disciplines involved in the co-treatment.
- Step 3: Ensure that the therapy sessions involved different treatment goals from each therapist.
- Step 4: Enter the total number of co-treatment minutes for occupational therapy in O0400B3A.
4. Coding Tips
- Record Therapy Time Accurately: Both therapists can record the full session duration in their respective therapy sections as co-treatment minutes.
- Verify Clinical Justification: Ensure that the co-treatment was clinically appropriate for the resident and not overused. Co-treatment should be justified and documented in the care plan.
- Distinct Treatment Goals: Each discipline must have a distinct goal or intervention during the co-treatment session.
5. Documentation
Objective: Ensure that the documentation supports the co-treatment sessions and the role of each therapist.
Actions:
- Include detailed notes in the resident’s therapy records about the co-treatment sessions, including the rationale for using co-treatment.
- Document the specific therapy interventions provided by each therapist and how the co-treatment contributed to the resident’s progress.
6. Common Errors to Avoid
- Misclassifying Concurrent Therapy: Do not confuse concurrent therapy (two residents treated by one therapist) with co-treatment (two therapists treating one resident simultaneously).
- Inadequate Documentation: Ensure that the rationale for co-treatment and the specific interventions provided by each therapist are clearly documented.
- Overuse of Co-Treatment: Co-treatment should be used sparingly and only when necessary for the resident’s care.
7. Practical Application
- Example 1: A resident received a co-treatment session involving both occupational therapy (for upper body strengthening) and physical therapy (for balance training). The OT and PT can each report the full session duration in their respective sections, and O0400B3A is coded with the co-treatment minutes.
- Example 2: A resident participated in a therapy session where both OT and speech therapy were present. Since each therapist worked on different goals (ADL skills for OT and cognitive exercises for ST), the session is documented as co-treatment in both sections.
Please note that the information provided in this guide for MDS 3.0 Item set O0400B3A was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
